title: Perceptions of the usefulness of external support to immunization coverage in Chad: an analysis of the GAVI-Alliance cash-based support.
abstract: BACKGROUND
  Chad is one of the countries supported by the GAVI-Alliance that remains with unsatisfactory vaccination coverage. This paper tries to understand the main barriers to better coverage.
  
  
  METHODS
  These barriers were categorised as up or downstream against the health system building blocks as proposed by WHO and compared with barriers and activities identified by the country in its health system's strengthening grant proposal as approved by the GAVI Alliance in 2007. Data were collected using a modified Delphi system and by analysis of grant and annual report documents.
  
  
  RESULTS
  Most of the activities anticipated under the GAVI health system's strengthening proposal are activities targeting downstream barriers (the neglect of upstream issues is of major importance in a decentralised state like Chad) and aligned with, not complementary to, immunization services strengthening activities. Further, both set of cash grants are blind to important recommendations such as the need to address barriers at the level of leadership and governance and at the level of the financing system and also about initiatives to promote community demand of vaccination services.
  
  
  CONCLUSIONS
  IN CHAD SLOW VACCINATION PROGRESS IS AGGRAVATED BY SEVERAL CONTEXTUAL BARRIERS: the size of the country, the low population density, the nomadic nature of a significant part of its peoples, the recent civil war, associated with civil unrest and political instability and its geographical localization. In this situation it would be important to sustain downstream operations (the major focus of the ISS grant) while taking a long term view of the needs of the health system. The GAVI effectively supports downstream operations, but neglects the long term view.
authors.affiliation: Department of International Public Health and Biostatistics, WHO Collaborating Centre for Health Workforce Policy and Planning, CMDT, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa. 1349-008, Lisbon, Portugal.
authors.forename: Paulo
authors.initials: P
authors.lastname: Ferrinho
authors.forename: Mohammed
authors.initials: M
authors.lastname: Dramé
authors.forename: Prosper
authors.initials: P
authors.lastname: Tumusiime
mesh_terms: D002596:Chad; D003697:Delphi Technique; D005381:Financing, Organized / Q000191:economics; D014943:Global Health / Q000191:economics; D006301:Health Services Needs and Demand / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D017589:Immunization Programs / Q000191:economics / Q000458:organization & administration*; D007391:International Cooperation; D013997:Time Factors; D014611:Vaccination / Q000191:economics / Q000706:statistics & numerical data*; D014612:Vaccines / Q000008:administration & dosage* / Q000191:economics
chemical_list: D014612:Vaccines
keywords: Africa; Chad; global health initiatives; immunization; vaccination coverage